Fundamentals PrepU Chapter 14: Implementing

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed?

"I must conduct research to validate the usefulness of my nursing interventions."

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the education and attempt at another time

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

Inform the client what to expect after the surgery.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Listen to the new nurse's suggestion and evaluate its usefulness

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed:

standing orders.

Which examples of nursing actions involve direct care of the client? Select all that apply.

-A nurse counsels a young family who is interested in natural family planning. -A nurse massages the back of a client while performing a skin assessment. -A nurse helps a client in hospice fill out a living will form.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

-The client is blind. -The client denies the need for education.

The surgeon is insisting that a client consent to a hysterectomy. The client says that she will not make a decision without her husband's consent. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to her husband

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?

Collaborate with other disciplines to revise the discharge plans.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant

The nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student

The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome evaluation

The emergency room has a strict protocol regarding IM (intramuscular) injection technique. A nurse working in the emergency room has learned of a new technique to decrease pain with IM injections and would like to use it. What is the most appropriate way for the nurse to implement the technique?

Petition to change the protocol based on the new evidence

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

Surveillance

The client reports right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site. Which type of intervention skill is the nurse using?

Technical skill -Technical skills are used to carry out treatments and procedures. Nurses learn the specific skills through clinical practice. Technical competence means being able to use equipment, machines, and supplies in a particular specialty.

When caring for a client in the emergency room who has presented with symptoms of a (MI) myocardial infarction, the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. In order for the nurse to be operating within the nurse's scope of practice, what conditions must be present?

The nurse is operating under standing orders for clients with MIs.

Which nursing action can be categorized as a surveillance or monitoring intervention?

auscultating of bilateral lung sounds

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

bed bath for the newly-admitted client who has multiple skin lesions

Nurses use the Nursing Outcomes Classification when choosing nursing goals for clients. What are the goals of the research that is behind the Nursing Outcomes Classification (NOC)? Select all that apply.

-To identify, label, and validate nursing-sensitive client outcomes and indicators -To evaluate the validity and usefulness of the classification in clinical field testing -To define and test measurement procedures for the outcomes and indicators

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to the client and assess the client's pain

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. What is the nurse's most appropriate action?

Reassess if the urinary catheter is still necessary for the client

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply.

-The client's respiratory rate decreases. -The client states, "I can breathe easier now." -The client's oxygen saturation level increases.

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply.

-assisting the client with personal hygiene needs and ambulation -transporting the infant to the mother's room according to hospital policy

A client with hypertension being seen for follow-up care has a blood pressure of 160/100. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action?

Report the findings to the physician for further plans

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: HR 74, RR 8, BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. What would allow the nurse to initiate this action?

Standing orders

A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first?

an asthma client who reports shortness of breath with a respiratory rate of 26 bpm

The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action?

Coordinate with the case manager to make a safe discharge plan

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self-care as possible

The nurse in a Burn Intensive Care Unit (BICU) is caring for a 3-year-old boy who was burned with scalding hot water. He has burns covering 75 percent of his body. His condition is critical but stable. At 1000, the nurse reassesses the client and finds that he is agitated and pulling at his endotracheal tube. What would be the nurse's priority?

ensuring that the endotracheal tube is secure

A client being treated with chemotherapy for breast cancer tells the nurse that she no longer wants to receive the medication because of the overwhelming nausea and vomiting. What is the best response by the nurse?

"I will consult with the health care provider to see how the nausea and vomiting can be prevented."

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response?

"I will not work tomorrow because I would be a danger to my clients."

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?

"We ask your name to ensure that we are treating the right client."

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Mark all that apply.

-The client verbalizes understanding of the instructions. -The client is able to answer the nurse's questions. -The client discusses the specifics of what was taught during the session.

The nurse assigned to care for a client that has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? (Select all that apply.)

-confirming the UAP has successfully passed this skill competency -being available for questions from the UAP -giving a report on the client to the UAP and answering questions -confirming that the UAP has repeatedly completed similar tasks

As part of the plan of care, a nurse administers scheduled pain medication to a postoperative client with a pain level of 6 on a 0 to 10 scale. Which action best represents the next step in the nursing process?

Assess pain level in 30 minutes

A nurse is preparing to educate a client about self-care after a cataract surgery. Which of the following would the nurse do first?

Determine the client's willingness to follow the regimen.

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action?

Praise the client for taking an active role in his care.

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

Psychosocial background

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention -Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses use these surveillance activities to determine the current status of clients and changes from previous states.

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action?

The nurse should address the concern with the surgeon

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that she does not have the experience to properly care for this client

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP?

Provide client assistance to the bedside commode